Post on 14-Mar-2018
transcript
Joint Commission Center for Transforming Healthcare
The Joint Commission’s Center for
Transforming Healthcare aims to solve
health care’s most critical safety and quality
problems. The Center’s participants –
leading health care organizations – use a
proven, systematic approach to analyze
specific breakdowns in patient care and
discover their underlying causes to develop
targeted solutions that solve these complex
problems. In keeping with its objective to
transform health care into a high reliability
industry, The Joint Commission shares these
proven effective solutions with the more than
20,000 health care organizations it accredits.
Reducing the Risk ofWrong Site Surgery
Wrong Site Surgery Project
Participants
• AnMed Health
• Center for Health Ambulatory
Surgery Center
• Holy Spirit Hospital
• La Veta Surgical Center
• Lifespan-Rhode Island
Hospital
• The Mount Sinai Medical
Center
• Seven Hills Surgery Center
• Thomas Jefferson University
Hospitals
Update: May 13, 2013
2Update: May 13, 2013
Why Wrong Site Surgery?
Everyone agrees that wrong site surgery is a
serious preventable adverse event. It should
never happen. Although reporting is not
mandatory in most states, some estimates put
the national incidence rate, which includes
wrong patient, wrong procedure, wrong site,
and wrong side surgeries, as high as 40 per
week. The estimate includes invasive
procedures that occur in many settings within
hospitals and ambulatory surgery centers,
including but not limited to operating rooms.
Some of the other hospital settings in which
invasive procedures occur include the
radiology and cardiology departments and
patients’ bedsides. The Joint Commission has
been at the forefront of the wrong site surgery
issue for many years. Its Sentinel Event
program first identified wrong site surgery as a
common type of sentinel event. The Joint
Commission has issued two Sentinel Event
Alert newsletters on wrong site surgery; the
first published in 1998 and the follow up in
2001. In 2003, The Joint Commission held its
first Wrong Site Surgery Summit and in 2004,
it launched the Universal Protocol. The Joint
Commission continues to press the urgency of
this issue, so it was only natural that the Cen-
ter for Transforming Healthcare would tackle
this problem as one if its first initiatives.
The Center for Transforming Healthcare
began collaborating with hospitals from
Lifespan in Rhode Island in 2009; four addi-
tional hospitals and three ambulatory surgical
centers joined the project in 2010. Like many
health care organizations throughout the
United States, these organizations recognize
that, while wrong site surgery is a rare
problem, all facilities and physicians who per-
form invasive procedures are at some degree
of risk. The magnitude of this risk is often
unknown or undefined. Providers who ignore
this fact, or rely on the absence of such
events in the past as a guarantee of future
safety, do so at their own peril. Unless an
organization has taken a systematic approach
to studying its own processes, it is flying blind.
This project addresses the problem of wrong
site surgery using Robust Process Improve-
ment™ (RPI) methods. RPI is a fact-based,
systematic, and data-driven problem-solving
methodology. It incorporates tools and
methods from Lean Six Sigma and change
management methodologies. Using RPI, the
project teams measure the magnitude of the
problem, pinpoint the contributing causes,
develop specific solutions that are targeted to
each cause, and thoroughly test the solutions
in real life situations.
Although invasive surgical procedures occur
in many settings, the scope of this project
included all procedures performed in the
operating room and all regional blocks
performed by anesthesia either in the
preoperative area or the operating room.
Within the project scope, the timeframe begins
at the time a procedure is scheduled for
surgery and ends with incision.
3
Wrong Site Surgery: Characteristics ofProject Participants
Anderson, South Carolina
Peoria, Illinois
Camp Hill, Pennsylvania
Orange, California
Providence, Rhode Island
New York, New York
Henderson, Nevada
Philadelphia, Pennsylvania
Hospital
Ambulatory Surgical Center
Hospital
Ambulatory Surgical Center
Hospital
Hospital
Ambulatory Surgical Center
Hospital
Site Location Type # of # of # ofBeds Surgeries Operating
Annually Rooms
These health care organizations represent a variety of settings, from
small to large, from rural to urban, both teaching and non-teaching.
Their differences serve to underscore the importance of managing
the risks of wrong site surgery. Whatever the size or scope of an
organization, preventing wrong site surgery is accomplished through
controlling the defects in the perioperative process from scheduling
to incision.
AnMed Health
Center for Health Ambulatory Surgery Center
Holy Spirit Hospital
La Veta Surgical Center
Lifespan - Rhode Island Hospital
The Mount Sinai Medical Center
Seven Hills Surgery Center
Thomas Jefferson University Hospitals
578
319
719
1,171
957
10,000
7,400
10,000+
6,600
24,399
32,267
5,000
38,214
18
6
15
5
33
49
7
57
Update: May 13, 2013
4
Update: May 13, 2013
Reducing Process Errors Reduces Risk of Wrong Site Surgery
Defects in the
Process
ProcessRisk
WrongSite
Surgery
Booking Errors
Verification Errors
Distractions/Rushing
Inconsistent Site Marking
No Safety Culture
Time Out Errors
Sc
he
du
lin
g
Pre
-op
/Ho
ldin
g
To reduce the risk of wrong site surgery, all potential errors
must be identified from scheduling to the operating room.
Wrong site surgeries are relatively rare events and, therefore, are difficult to study. Research has shown that there is usually no one root cause of failure. Instead, such
events are frequently the result of a cascade of small errors that are able to penetrate organizational defenses. In his 1997 book “Managing the Risks of Organizational
Accidents,” James Reason presents the Swiss Cheese Model of Defenses as a conceptual framework for studying and preventing unwanted outcomes. Organizations
design multiple layers of defenses—represented by the slices of the Swiss cheese—to protect against accidents and sentinel events. Defenses are imperfect, and
accidents happen when errors and weaknesses align. It is important to examine the failures in an organization’s defenses to fully understand the event and reduce the
risk of future failures. The organizations that participated in the Center’s Wrong Site Surgery project focused on finding and reducing weaknesses in the perioperative
process from scheduling to incision in an operative case.
Op
era
tin
g R
oo
mS
afe
ty P
rac
tic
es
an
d P
roc
ed
ure
s
5Update: May 13, 2013
The challenge is
t
These errors, i
T
D
!
!
!
)
T
Defective cases reduced from a baseline of 39%
to 21%
oi
nt C
omm
issi
on
The challenge is
t
These errors, i
T
!
!
!
)
The incidence of cases containing more than one
defect decreased 57%
D
Proportion of Defective Cases: Surgical Booking
The surgical booking process can generate many
errors. The challenge is that the physician offices
that supply this information are often not affiliated
directly with the organization. In fact, these offices
have many different facilities to work with, which can
lead to confusion. These errors, if left unaddressed,
can lead to delays and rushing the day of surgery and
increase the risk of wrong site surgery due, for
example, to operating room set-up errors. Information
on exactly how errors in the booking process arise
can present a great opportunity for collaboration and
quality improvement.
Defects identified in the surgical booking area are theresult of miscommunication between the organizationand physician offices, such as:1. Written booking forms not being received, resulting
in verbal bookings or last minute scheduling2. Incorrect or incomplete bookings where laterality
may or may not be addressed, inconsistencies between procedure codes and procedure descriptions, or incomplete identification of procedures
3. Legibility concerns and the use of abbreviationsthat are unapproved due to safety reasons (e.g. L instead of left)
When there is improvement in the proportion of defective cases at the time of surgical
booking, the likelihood of those errors leading to a wrong site surgery goes down.
These data highlight the importance of hospitals and ambulatory surgical centers
collaborating directly with physician practices to reduce booking errors.
Defective cases reduced
from a baseline of 39% to 21%
(p-value = 0.000, N = 5)
6Update: May 13, 2013 © C
opyr
ight
, The
Joi
nt C
omm
issi
on
Since a single operative case has multiple opportunities for defects, improvement was also seen the number of defects per case with the
incidence of more than one defect being found reduced substantially as well as the number of defect free cases increasing
Defects occurring in the pre-op and pre-op holding areas have a lot to do documentation errors 1.! Incomplete and incorrect
documents (history and physical, consent, and OR schedule)
2.! Lack of verification of patient name and second identifier, procedure, procedure site, and laterality
3.! Missing documents, particularly missing history and physicals and consent documents
4.! Changes made to the consent in the pre-op area without OR notification
Pre-op/Pre-op Holding
Not all facilities have a separate pre-op holding area, this is particularly true for ambulatory surgical centers. When there are two separate areas, it is common for problems to be identified in the pre-op area but not resolved until the patient reaches the pre-op holding room. The data collected in these two areas used the same audit tool.
Defective cases reduced from a baseline of 52%
to 19%
The incidence of cases containing more than one
defect decreased 72%
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Since a single operative case has multiple opportunities for defects, improvement was also seen the number of defects per case with the
incidence of more than one defect being found reduced substantially as well as the number of defect free cases increasing
Defects occurring in the pre-op and pre-op holding areas have a lot to do documentation errors 1.! Incomplete and incorrect
documents (history and physical, consent, and OR schedule)
2.! Lack of verification of patient name and second identifier, procedure, procedure site, and laterality
3.! Missing documents, particularly missing history and physicals and consent documents
4.! Changes made to the consent in the pre-op area without OR notification
Pre-op/Pre-op Holding
Not all facilities have a separate pre-op holding area, this is particularly true for ambulatory surgical centers. When there are two separate areas, it is common for problems to be identified in the pre-op area but not resolved until the patient reaches the pre-op holding room. The data collected in these two areas used the same audit tool.
Defective cases reduced from a baseline of 52%
to 19%
The incidence of cases containing more than one
defect decreased 72%
Proportion of Defective Cases: Pre-op/Pre-op Holding
Not all facilities have a separate pre-op/holding area.
This is particularly true for ambulatory surgical
centers. When there are two separate areas, it is
common for problems to be identified in the pre-op
area, but not resolved until the patient reaches the
pre-op/holding room. Project participants used a
standard data collection tool to collect data on risk
points. The data collected in these two areas used
the same data collection tool.
Defects occurring in the pre-op/holding areas have a
great deal to do with documentation errors. These
include:
1. Incomplete or incorrect documents such as
history and physical, consent, and operating room
schedule
2. Lack of verification of patient name and second
identifier, procedure, procedure site, and laterality
3. Missing documents such as history and physical
consent
4. Changes made to the consent in the pre-op area
without operating room notification
Defects introduced at one stage of the peri-operative process increase the risk
of wrong site surgery occuring in the operating room. These data demonstrate the
effectiveness of interventions to reduce defects at the pre-operative stage.
Defective cases reduced
from a baseline of 52% to 19%
(p-value = 0.000, N = 6)
7Update: May 13, 2013
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Fortunately, wrong site surgery events rarely occur therefore this project measures opportunities for error (Defects) that could result in a wrong site surgery event. Examples include, surgical site marking not being performed, staff inattention during the time out process, the time out lacking critical information such as etc. These results depict the risk reduction that the organizations experienced from baseline findings through implementation of improvements in the operating room.
Since a single operative case has multiple opportunities for defects, improvement was also seen the number of defects per
case with the incidence of more than one defect being found reduced substantially.
Defects occurring in the operating room have a lot to do with site marking and team attention during the time out process 1.! Procedural site marking (use
of unapproved site marking pen, mark not visible after prep and drape, every procedure is not marked, team members do not reference the site)
2.! Critical elements of the time out are not verbalized (patient name, second identifier, procedure, site and laterality)
3.! Rushing (missing equipment, staff)
The Operating Room
The incidence of cases containing more than one
defect decreased 76%
Defective cases reduced from a baseline of 59%
to 29%
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Fortunately, wrong site surgery events rarely occur therefore this project measures opportunities for error (Defects) that could result in a wrong site surgery event. Examples include, surgical site marking not being performed, staff inattention during the time out process, the time out lacking critical information such as etc. These results depict the risk reduction that the organizations experienced from baseline findings through implementation of improvements in the operating room.
Since a single operative case has multiple opportunities for defects, improvement was also seen the number of defects per
case with the incidence of more than one defect being found reduced substantially.
Defects occurring in the operating room have a lot to do with site marking and team attention during the time out process 1.! Procedural site marking (use
of unapproved site marking pen, mark not visible after prep and drape, every procedure is not marked, team members do not reference the site)
2.! Critical elements of the time out are not verbalized (patient name, second identifier, procedure, site and laterality)
3.! Rushing (missing equipment, staff)
The Operating Room
The incidence of cases containing more than one
defect decreased 76%
Defective cases reduced from a baseline of 59%
to 29%
Proportion of Defective Cases: Operating RoomFortunately, wrong site surgery events do not occur
often. This project therefore measures opportunities
for errors (defects) that increase the risk of a wrong
site surgery event. Examples include surgical site
marking not being performed; staff inattention during
the Time Out process; and the Time Out lacking
critical information. These results depict the risk
reduction that the organizations experienced from
baseline findings through implementation of
improvements in the operating room.
Defects identified in the operating room have more
to do with site marking defects and team attention
during the time out process:
1. Procedural site marking such as the use of
unapproved site marking pen, mark not visible
after prep and drape, every procedure is not
marked, team members do not reference the site
2. Critical elements of the Time Out are not verbal-
ized, such as patient name, second identifier,
procedure, site and laterality
3. Staff is rushing during the Time Out and critical
steps are missed
A single operative case has multiple opportunities for defects. When there are
multiple defects in a single case, it can increase the risk of an error reaching
the patient. These data demonstrate the effectiveness of the interventions in
substantially reducing the proportion of cases with multiple defects
while increasing those with no defects.
Defective cases reduced
from a baseline of 59% to 29%
(p-value = 0.000, N = 6)
8Update: May 13, 2013
Main Causes of Wrong Site Surgeries
These contributing factors vary by organizationand by event. This underscores the importance of understanding specific root causes so that appropriate solutions can be targeted.
Scheduling
• Booking documents not verified by office schedulers
• Schedulers accept verbal requests for surgical bookings instead of written documents
• Unapproved abbreviations, cross-outs,and illegible handwriting used on booking form
• Missing consent, history and physical, or surgeon’s orders at time of booking
Pre-op/Holding
• Primary documents (consent, history and physical, surgeon’s booking orders, operating room schedule) missing, inconsistent or incorrect
• Paperwork problems identified in pre-opbut resolved in a different location
• Inconsistent use of site marking protocol
• Someone other than surgeon marks site
• Surgeon does not mark site in pre-op/holding
• Site mark made with non-approved surgical site marker
• Stickers used in lieu of marking the skin
• Inconsistent site marks used by physicians
• Inconsistent or absent Time Out processfor regional blocks
• Rushing during patient verification
• Alternate site marking process does notexist or is not used
• Inadequate patient verification by team
Operating Room
• Lack of intraoperative site verificationwhen multiple procedures performed bythe same provider
• Ineffective hand-off communication orbriefing process
• Primary documentation not used to verify patient, procedure, site and side
• Site mark(s) removed during prep or covered by surgical draping
• Distractions and rushing during Time Out
• Time Out process occurs before all staffare ready or before prep and drape occurs
• Time Out performed without full participation
• Time Outs do not occur when there aremultiple procedures performed by multi-ple providers in a single operative case
Organizational Culture
• Senior leadership is not actively engaged
• Inconsistent organizational focus on patient safety
• Staff is passive or not empowered tospeak up
• Policy changes made with inadequate orinconsistent staff education
• Marketplace competition and pressure toincrease surgical volume leads to shortcuts and variation in practice
We are often asked about the relationship of the Center for
Transforming Healthcare to The Joint Commission’s current
accreditation requirements. The Center was established to
examine and produce effective solutions for today’s most
vexing safety and quality problems. Many of these are
identified in Joint Commission accreditation requirements
(such as National Patient Safety Goals) as problems health
care organizations need to work on. The Center develops
solutions that organizations can implement to reduce the
harm of these quality problems. Very often, Joint Commission
accreditation requirements specify a problem (e.g., maintain-
ing hand hygiene compliance) that health care organizations
should have an effective way to manage, and the Center
provides effective ways to manage that problem.
It is important to note that the work of the Center is conducted
separately from the standards development and accreditation
process, though it may ultimately drive changes to both.
Some solutions that emanate from Center projects may go
beyond current Joint Commission requirements. However, in
no way should it be construed that the work of the Center
contradicts or is in conflict with Joint Commission require-
ments. All Center solutions developed to date are fully
consistent with applicable Joint Commission accreditation
requirements. These solutions are intended to help health
care organizations create more reliable processes and
achieve high levels of consistent excellence.
9Update: May 13, 2013
Validated Root Causes for Risk of Wrong Site Surgery
Note that not all of the main causes of failure appear in every hospital or ambulatory surgical center. The chart
above represents the validation of the root causes across the pilot sites. This underscores the importance of
understanding specific root causes so that appropriate solutions can be targeted.
A B C D E F G H
Booking documents not verified by office schedulers
Schedulers accept verbal requests for surgical bookings instead of written documents
Unapproved abbreviations, cross-outs, and illegible handwriting used on booking form
Missing consent, history and physical, or surgeon’s orders at time of booking
Primary documents (consent, history and physical, surgeon’s booking orders, operating room schedule)missing, inconsistent or incorrect
Paperwork problems identified in pre-op but resolved in a different location
Inconsistent use of site marking protocol
Someone other than surgeon marks site
Surgeon does not mark site in pre-op/holding
Site mark made with non-approved surgical site marker
Stickers used in lieu of marking the skin
Inconsistent site marks used by physicians
Inconsistent or absent Time Out process for regional blocks
Rushing during patient verification
Alternate site marking process does not exist or is not used
Inadequate patient verification by team
x x x
x x x x x x
x x x x x x x x
x x x x x x x x
x x x x x x x x
x x x
x x x x x
x x x
x x x x
x x x
x
x x x x x
x x x x x
x x x x x x x
x
x x x x x x
Pilot Hospitals and Ambulatory Surgical Centers
Sc
he
du
lin
gP
re-o
p/H
old
ing
10Update: May 13, 2013
Validated Root Causes for Risk of Wrong Site Surgery
A B C D E F G H
Lack of intraoperative site verification when multiple procedures performed by the same provider
Ineffective hand-off communication or briefing process
Primary documentation not used to verify patient, procedure, site and side
Site mark(s) removed during prep or covered by surgical draping
Distractions and rushing during Time Out
Time Out process occurs before all staff are ready or before prep and drape occurs
Time Out performed without full participation
Time Outs do not occur when there are multiple procedures performed by multiple providers
in a single operative case
Senior leadership is not actively engaged
Inconsistent organizational focus on patient safety
Staff is passive or not empowered to speak up
Policy changes made with inadequate or inconsistent staff education
Marketplace competition and pressure to increase surgical volume leads to
shortcuts and variation in practice
x x x x x x x
x x x x x
x x x x x
x x x x x x
x x x x x x x x
x x x x x x x
x x x x x x x x
x
x x x
x x x x x
x x x x x x x x
x x x x x
x x x x x
Op
era
tin
g R
oo
mO
rga
niz
ati
on
al
Cu
ltu
re
Pilot Hospitals and Ambulatory Surgical Centers
Note that not all of the main causes of failure appear in every hospital or ambulatory surgical center. The chart
above represents the validation of the root causes across the pilot sites. This underscores the importance of
understanding specific root causes so that appropriate solutions can be targeted.
11Update: May 13, 2013
Solutions for Reducing the Risk of Wrong Site Surgery
Reinforce Quality and Measurement
• Demonstrate leadership’s commitment to
implement standardized work processes for
all steps–scheduling, pre-op/holding and
operating room
• Utilize an ongoing measurement system for
identifying inconsistencies in real time
• Hold all caregivers and staff accountable for
their role in risk reduction; organization
should define roles
• Monitor compliance of standardized work
processes, tools and methods in all steps of
the process (scheduling/booking,
pre-op/holding, operating room)
• Make it easy
> Build on relationships with physician
offices to improve the accuracy of
information received and methods used to
confirm the accuracy of the operating
room schedule
> Limit entry points for primary documenta-
tion (consent, history and physical,
physician orders, booking/scheduling
form) to a single fax number
> Work with operating room team to develop
a role-based Time Out process that works
for your organization
Safety Culture
• Create an environment in which staff are
expected to speak up when they have a
patient safety concern
• Utilize a team approach when teaching all
staff how the process should be executed
• Celebrate success; everyone should be
aware of improvements
• Provide ongoing education and coaching
Knowledge
• Examine processes for inconsistencies
and seek to understand the cause of
variation
• Educate staff by using active learning
techniques rather than communicating
only through e-mails or posters
• Provide rationale for changes important to
implement even if a wrong site surgery event
has not occurred
• Describe the rationale to staff and explain
why standardized processes are important
• Share the data and allow the team to ask
questions
• Empower all team members to participate
in processes designed to reduce the risk
of wrong site surgery; everyone should
be expected to speak up
We are often asked about the relationship of the Center for
Transforming Healthcare to The Joint Commission’s current
accreditation requirements. The Center was established to
examine and produce effective solutions for today’s most
vexing safety and quality problems. Many of these are
identified in Joint Commission accreditation requirements
(such as National Patient Safety Goals) as problems health
care organizations need to work on. The Center develops
solutions that organizations can implement to reduce the
harm of these quality problems. Very often, Joint Commission
accreditation requirements specify a problem (e.g., maintain-
ing hand hygiene compliance) that health care organizations
should have an effective way to manage, and the Center
provides effective ways to manage that problem.
It is important to note that the work of the Center is conducted
separately from the standards development and accreditation
process, though it may ultimately drive changes to both.
Some solutions that emanate from Center projects may go
beyond current Joint Commission requirements. However, in
no way should it be construed that the work of the Center
contradicts or is in conflict with Joint Commission require-
ments. All Center solutions developed to date are fully
consistent with applicable Joint Commission accreditation
requirements. These solutions are intended to help health
care organizations create more reliable processes and
achieve high levels of consistent excellence.
12Update: May 13, 2013
• Standardize processes to:
> Confirm the accuracy of the operating
room schedule
> Confirm the presence and accuracy of
primary documents critical to the
verification process prior to the day of
surgery (signed surgical consent, history
and physical, and physician orders)
> Confirm identification of patient by all team
members using patient armband, patient
speak back, or patient caregiver if patient
has been sedated
> Mark in the pre-op/holding area performed
by the surgeon using a single-use surgical
skin marker with a consistent mark type
(e.g., surgeon’s initials) placed as close as
anatomically possible to the incision site
• Do not move patient to the operating
room before surgeon has marked the site
> Mark the site for every procedure; if not
possible, document why a site mark was
not performed
> Verify all regional blocks using a
standardized Time Out process
> Perform a pre-operative briefing in the
operating room with patient involvement, if
possible, to verify patient identity, proce-
dure site and side, along with other critical
elements that need to be verified and
addressed but are not part of the Time Out
process.
These include:
> Verify correct implant availability
> Verify blood product availability
> Verify presence of operative films,
including the correct orientation
> Identify any special considerations (i.e.
allergies, antibiotics)
• Perform a standardized Time Out process,
which occurs after the prep and drape,
and includes the following elements:
> Perform role-based Time Out in which
every team member has an active role to
play in the process
> Point and touch verification of the
surgical site mark by the surgeon and
scrub technician
> Address any concerns by the team
before proceeding
> Reduce noise and cease all other
activity in operating room
• Perform a pause between each procedure
that occurs within a single case to ensure
that each procedure is performed
accurately and according to the procedure,
site and laterality contained within the
signed surgical consent
• Separate Time Out for procedures that
have a change in surgeon
Improve Consistency in ProcessSolutions forReducing the Risk ofWrong Site Surgery
13Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsBooking documents not verified by office schedulers
Schedulers accept verbal requests for surgicalbookings instead of written documents
Unapproved abbreviations, cross-outs, and illegible handwriting used on booking form
Missing consent, history and physical, or surgeon’s orders at time of booking
• Confirm the accuracy of the operating room schedule
• Build on relationships with physician offices to improvethe accuracy of information received and methods used toconfirm the accuracy of the operating room schedule
• Confirm the accuracy of the operating room schedule
• Limit entry points for primary documentation (consent, history and physical, physician orders, booking/schedulingform) to a single fax number
• Monitor compliance of standardized work processes, toolsand methods in all steps of the process (scheduling/book-ing, pre-op/holding, operating room)
• Build on relationships with physician offices to improvethe accuracy of information received and methods used toconfirm the accuracy of the operating room schedule
• Confirm the presence and accuracy of primary documentscritical to the verification process prior to the day of sur-gery (signed surgical consent, history and physical, andphysician orders)
• Build on relationships with physician offices to improvethe accuracy of information received and methods used toconfirm the accuracy of the operating room schedule
• Limit entry points for primary documentation (consent,history and physical, physician orders, booking/schedulingform) to a single fax number
14Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsPrimary documents (consent, history andphysical, surgeon’s booking orders, operatingroom schedule) missing, inconsistent or incorrect
Paperwork problems identified in pre-op butresolved in a different location
Inconsistent use of site marking protocol
• Confirm the presence and accuracy of primary documentscritical to the verification process prior to the day of surgery (signed surgical consent, history and physical, andphysician orders)
• Limit entry points for primary documentation (consent, history and physical, physician orders, booking/schedulingform) to a single fax number
• Build on relationships with physician offices to improve the accuracy of information received and methods used toconfirm the accuracy of the operating room schedule
• Share the data and allow the team to ask questions
• Create an environment in which staff are expected tospeak up when they have a patient safety concern
• Create an environment in which staff are expected tospeak up when they have a patient safety concern
• Mark the site for every procedure; if not, document why asite mark was not performed
• Do not move patient to the operating room before surgeonhas marked the site
• Mark in the pre-op/holding area performed by the surgeonusing a single-use surgical skin marker with a consistentmark type (e.g., surgeon’s initials) placed as close asanatomically possible to the incision site
• Examine processes for inconsistencies and seek to understand the cause of variation
15Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsSomeone other than surgeon marks site
Surgeon does not mark site in pre-op/holding
• Mark the site for every procedure; if not possible , document why a site mark was not performed
• Do not move patient to the operating room before surgeonhas marked the site
• Mark in the pre-op/holding area performed by the surgeonusing a single-use surgical skin marker with a consistentmark type (e.g., surgeon’s initials) placed as close asanatomically possible to the incision site
• Examine processes for inconsistencies and seek to under-stand the cause of variation
• Mark the site for every procedure; if not possible, document why a site mark was not performed
• Do not move patient to the operating room before surgeonhas marked the site
• Mark in the pre-op/holding area performed by the surgeonusing a single-use surgical skin marker with a consistentmark type (e.g., surgeon’s initials) placed as close asanatomically possible to the incision site
• Create an environment in which staff are expected tospeak up when they have a patient safety concern
16Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsSite mark made with non-approved surgicalsite marker
Stickers used in lieu of marking the skin
Inconsistent site marks used by physicians
• Do not move patient to the operating room before surgeonhas marked the site
• Mark in the pre-op/holding area performed by the surgeonusing a single-use surgical skin marker with a consistentmark type (e.g., surgeon’s initials) placed as close asanatomically possible to the incision site
• Mark in the pre-op/holding area performed by the surgeonusing a single-use surgical skin marker with a consistentmark type (e.g., surgeon’s initials) placed as close asanatomically possible to the incision site
• Provide rationale for changes important to implement evenif a wrong site surgery event has not occurred
• Do not move patient to the operating room before surgeonhas marked the site
• Mark in the pre-op/holding area performed by the surgeonusing a single-use surgical skin marker with a consistentmark type (e.g., surgeon’s initials) placed as close asanatomically possible to the incision site
• Provide ongoing education and just-in-time coaching
17Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsInconsistent or absent Time Out process for regional blocks
Rushing during patient verification
Alternate site marking process does not existor is not used
Inadequate patient verification by team
• Verify all regional blocks using a standardized Time Outprocess
• Describe the rationale to staff for why standardizedprocesses are important
• Monitor compliance of standardized work processes, toolsand methods in all steps of the process (scheduling/book-ing, pre-op/holding, operating room)
• Hold all caregivers and staff accountable for their role inrisk reduction; organization should define roles
• Create an environment in which staff are expected tospeak up when they have a patient safety concern
• Mark the site for every procedure; if not possible, document why a site mark was not performed
• Describe the rationale to staff for why standardizedprocesses are important
• Do not move patient to the operating room before surgeonhas marked the site
• Confirm identification of patient by all team membersusing patient armband, patient speak back, or patient cargiver if patient has been sedated
• Examine processes for inconsistencies and seek to understand the cause of variation
18Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsLack of intraoperative site verification when multiple procedures performed by the sameprovider
Ineffective hand-off communication or briefingprocess
Primary documentation not used to verify patient, procedure, site and side
• Perform a pause between each procedure that occurswithin a single case to ensure that each procedure is per-formed accurately and according to the procedure, siteand laterality contained within the signed surgical consent
• Perform a pre-operative briefing in the operating room withpatient involvement, if possible, to verify patient identity,procedure site and side, along with other critical elementsthat need to be verified and addressed but are not part ofthe Time Out process.
• Examine processes for inconsistencies and seek to under-stand the cause of variation
• Perform a pre-operative briefing in the operating room withpatient involvement, if possible, to verify patient identity,procedure site and side, along with other critical elementsthat need to be verified and addressed but are not part ofthe Time Out process.
• Confirm identification of patient by all team membersusing patient armband, patient speak back, or patient cargiver if patient has been sedated
• Monitor compliance of standardized work processes, toolsand methods in all steps of the process (scheduling/book-ing, pre-op/holding, operating room)
19Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsSite mark(s) removed during prep or coveredby surgical draping
Distractions and rushing during Time Out
• Examine processes for inconsistencies and seek to under-stand the cause of variation
• Provide rationale for changes important to implement evenif a wrong site surgery event has not occurred
• Perform a standardized Time Out process, which occursafter the prep and drape, and includes the following elements:
> Perform role-based Time Out in which every team member has an active role to play in the process
> Point and touch verification of the surgical site mark by the surgeon and scrub technician
> Address any concerns by the team before proceeding
> Reduce noise and cease all other activity in operating room
• Work with operating room team to develop a role-basedTime Out process that works for your organization
20Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsTime Out process occurs before all staff areready or before prep and drape occurs
• Perform a standardized Time Out process, which occursafter the prep and drape, and includes the following elements:
> Perform role-based Time Out in which every team member has an active role to play in the process
> Point and touch verification of the surgical site mark by the surgeon and scrub technician
> Address any concerns by the team before proceeding
> Reduce noise and cease all other activity in operating room
• Perform a pre-operative briefing in the operating room withpatient involvement, if possible, to verify patient identity,procedure site and side, along with other critical elementsthat need to be verified and addressed but are not part ofthe Time Out process.
• Work with operating room team to develop a role-basedTime Out process that works for your organization
• Empower all team members to participate in processesdesigned to reduce the risk of wrong site surgery; every-one is expected to speak up
21Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsTime Out performed without full participation • Perform a standardized Time Out process, which occurs
after the prep and drape, and includes the following elements:
> Perform role-based Time Out in which every team member has an active role to play in the process
> Point and touch verification of the surgical site mark by the surgeon and scrub technician
> Address any concerns by the team before proceeding
> Reduce noise and cease all other activity in operating room
• Educate staff by using active learning techniques ratherthan communicating only through e-mails or posters
• Demonstrate leadership’s commitment to implement standardized work processes for all steps–scheduling, pre-op/holding and operating room
• Monitor compliance of standardized work processes, toolsand methods in all steps of the process (scheduling/book-ing, pre-op/holding, operating room)
• Provide rationale for changes important to implement evenif wrong site surgery event has not occurred
• Work with operating room team to develop a role-basedTime Out process that works for your organization
• Create an environment in which staff are expected tospeak up when they have a patient safety concern
• Describe the rationale to staff for why standardizedprocesses are important
• Utilize a team approach when teaching all staff how theprocess should be executed
• Provide ongoing education and just-in-time coaching
22Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsTime Outs do not occur when there are multiple procedures performed by multipleproviders in a single operative case
Senior leadership is not actively engaged
• Examine processes for inconsistencies and seek to under-stand the cause of variation
• Provide rationale for changes important to implement evenif a wrong site surgery event has not occurred
• Perform a standardized Time Out process, which occursafter the prep and drape, and includes the following elements:
> Perform role-based Time Out in which every team member has an active role to play in the process
> Point and touch verification of the surgical site mark by the surgeon and scrub technician
> Address any concerns by the team before proceeding
> Reduce noise and cease all other activity in operating room
• Separate Time Out for procedures that have a change insurgeon
• Demonstrate leadership’s commitment to implement standardized work processes for all steps–scheduling, pre-op/holding and operating room
• Hold all caregivers and staff accountable for their role inrisk reduction; organization should define roles
23Update: May 13, 2013
Identifying Causes, Targeting Solutions
Causes SolutionsInconsistent organizational focus on patient safety
Staff is passive or not empowered to speak up
Policy changes made with inadequate or inconsistent staff education
Marketplace competition and pressure to increase surgical volume leads to shortcutsand variation in practice
• Utilize an ongoing measurement system for identifying inconsistencies in real time
• Hold all caregivers and staff accountable for their role inrisk reduction; organization should define roles
• Empower all team members to participate in processesdesigned to reduce the risk of wrong site surgery; everyone should be expected to speak up
• Share the data and allow the team to ask questions
• Work with operating room team to develop a role-basedTime Out process that works for your organization
• Create an environment in which staff are expected tospeak up when they have a patient safety concern
• Work with operating room team to develop a role-basedTime Out process that works for your organization
• Utilize a team approach when teaching all staff how theprocess should be executed
• Provide ongoing education and just-in-time coaching
• Celebrate success; everyone should be aware of improvements
• Create an environment in which staff are expected tospeak up when they have a patient safety concern
• Examine processes for inconsistencies and seek to understand the cause of variation